Kuliah Tk IV Fkui Diarrhoea

7/30/2019 Kuliah Tk IV Fkui Diarrhoea

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DIARRHEAPRAMITA G. DWIPOERWANTORODivision of Gastroenterology Child Health Department

Medical Faculty - University of Indonesia


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INTRODUCTION

Global problem morbidity & mortality

Definition: - Frequency & consistency

- Acute diarrhea

Dysentery

Persistent diarrhea

- Osmotic diarrhea

Secretory diarrhea

- Chronic diarrhea


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EPIDEMIOLOGY

Transmission of agents cause diarrhea

Routes of transmission

Behaviours

the risk of diarrhea Host factors susceptibility to diarrhea

Age

Seasonality

Asymptomatic infections

Epidemic


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BEHAVIOURS

Failing to breast-feed for the first 4-6 mos

Failing to continue breast-feeding 1 yr

Using infant feeding bottles Storing cooked food at room temperature

Drinking water contaminated w/ fecal

Failing to wash hands

Failing to dispose of faeces hygienically


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HOST FACTORS

Undernutrition

Current or recent measles Immunodeficiency or immunosuppresion


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HOST - malnutrition- immune deficiency

ENVIRONMENT AGENT

- sanitation - bacteria- hygiene - viruses

- protozoa


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ETIOLOGY

General considerations

Pathogenetic mechanisms: Viruses patchy epithelial cell destruction &

villous shortening Bacteriamucosal adhesion, invasion, toxin

Protozoamucosal adhesion,microabcess/ulcers

Important enteropathogens Rotavirus, ETEC, Shigella, C.jejuni, V.cholerae

01 Salmonella, Cryptosporidium


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Normal intestinal fluid balance

Oral intake (1-2L/day)

+ saliva (1.5L)

+ stomach + pancreas + liver (5-6L)

Jejunum 9L enter the small intestine/day

H2O + Na+,Cl-,K+ simultaneously absorbed

(8L/d) Ileum HCO3- excreted

1-1.5L enter colon/day

Colon

Na+ & Cl- absorbed

K+ & HCO3- excreted

100-200mls of water being excreted each day in formed stool


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Intestinal absorption of water & electrolytes

Absorption osmotic gradients solutes (Na+)

are actively absorbed from the bowel by the

villous epithelial cells

Mechanisms of Na+ absorption: Linked to the absorption of Cl-

Absorbed directly as sodium ion

Exchanged for hydrogen ion

Linked to the absorption of organic materials (glucose

/ amino acids)


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Intestinal secretion of water & electrolytes

Occurs in the crypts of the small bowel epithel NaCl is transported from ECF into the epithelialcells across its basolateral membrane

Na

+

pumped back

ECF by Na-K-ATPase Secretory stimuli the ability of Cl- to pass

through the luminal membrane of the crypt cells ion enter the bowel lumen

Movement of chloride ion osmotic gradient water & electrolytes flow passively from ECF intolumen through intercellular channels


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Pathophysiology

Mechanism of watery diarrhea:

Secretory diarrhea &/or osmotic diarrhea

Consequences of watery diarrhea: Isotonic dehydration

Hypertonic (hypernatraemic) dehydration

Hypotonic (hyponatraemic) dehydration

Base deficit acidosis (metabolic acidosis)

Potassium depletion


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SECRETORY DIARRHEA

Pathogen (eg: Yersinia)

produces

Toxins ATP

attached activates breakdown into

cAMPepithelium causes

of bowel

More secretion of chloride

andLoses absorption of sodium

Water, potasium & bicarbonate flow into the bowel

Watery stool with sodium, potasium, chloride & bicarbonate


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Invasive enteropathogens: Shigella

EIEC (Enteroinvasie E. coli)

C. jejuni

Salmonella

E. histolytica

Y. enterocolica

Enteropathogen causing secretory

diarrhea: V. cholerae 01

Enterotoxigenic E. coli (ETEC)

V. cholera non 01


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Mechanism of diarrhea in lactose

intolerance

BOWEL LUMEN

lactose

not absorbed

fermented bacteria

organic acid + gas

increased osmotic pressure

fluid dragged into lumen

diarrhea


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Composition of electrolytes in stool

Etiology Electrolytes (mmol/L) Osmolarity

(mosmol)Na K Cl HCO3

Cholera

Rotavirus

ETEC

Oralit WHO

88

37

53

90

30

38

37

20

86

22

24

80

32

6

18

30

300

300

300

300


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DIARRHEA MANAGEMENT

Assessing a child for dehydration: Ask,look, and feel for signs of dehydration

Condition & behaviour, eyes, tears, mouth & tongue

thirst, skin pinch

Anterior fontanelle, arms & legs, pulse, breathing

Determine the degree of dehydration

Select a treatment plan: C: Severe dehydration (loss of >10% of Body Weight)

B: Some dehydration (loss of 5-10% of BW) A: No signs of dehydration (loss of


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Signs & symptoms of some

dehydration

Restless, irritable

Sunken eyes

No tears when he cries vigorously

Dry mouth and tongue

Thirst drink eagerly

Slowly skin pinch (skin turgor)


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Signs & symptoms of severe dehydration

Floppy (listless), lethargic, or

unconscious

Very sunken & dry eyesNo tears when he cries

Very dry mouth & tongue

Is unable to drink / drink poorly Skin pinch: very slowly (take 2

seconds)


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DIARRHEA MANAGEMENT

Assessing the child for other problems

Dysentery

Persistent diarrhea

Under-nutrition

Feeding history

Physical findings: marasmic &/ kwashiorkor

Vitamin A deficiency

Fever

Measles vaccination status


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TREATMENT OF DIARRHEA

AT HOME (Plan A)

Prepare & give appropriate fluids for ORT

Feed a child with diarrhea correctlyRecognize when a child should be taken

to health worker


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TREATMENT OF DIARRHEA

Plan B: Manage in ORS corner

Continue breast-feeding

Give ORS 75mls/kg/3 hoursMonitor Tx & reassess the child

periodically until rehydration is complete

send home (Plan A)

Give ORS 10 mls/kg for each diarrhea

Resume giving foods other than BM after 4

hrs


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FAILURE OF ORT

The passage of many watery stools

Repeated vomiting

Increased thirst Failure to eat or drink normally

Severe dehydration

Meteorism Preparing & giving ORS not correctly


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WHEN TO TAKE THE CHILD TO A HEALTH WORKER

There is no improvement in 3 days

The passage of many watery stools

Repeated vomiting Increased thirst

Failure to eat or drink normally

Fever Blood in the stool


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INDICATION OF IV FLUID

Severe dehydration or with hypovolemia

Unable to drink (unconscious)

Persisted vomiting Prolonged oligouria or anuria

Other complications that influenced

ORS


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WHO ORS COMPOSITION

Contain

Sodium chloride

Three sodium citrate

(dihydrate)

Sodium bicarbonate

Potasium chloride

Glucose (anhydrate)

Gram/L

3.5

2.9

2.5

1.5

20.0

Composition

Sodium

Potasium

Chloride

Citrate

Bicarbonate

Glucose

Mmol/L

90

20

80

10

30

111


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COMPOSITION OF IV FLUID

Solution Glukosa

(g/L)

K+ Na+ Cl- Lactate/

Acetate

Hartmann / RL

DGaa

NaCl 0.9%

KaEN 3B

-

150

-

27

4

17.5

-

20

130

61

154

50

109

52

154

50

28

26

0

20


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TREATMENT FOR SEVERE DEHYDRATION

(PLAN C)

Give 100ml/kg:

*can be repeated if the pulse is still weak or unpalpable

Age 30ml/kg 70ml/kg

12 months

1 hour*

30min*-1hour

5 hours

2-2 hours


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ANTIBIOTICS FOR DIARRHEA

Cholera tetracycline or doxycycline

(if resistant: furazolidone, cotrimoxazole

or chloramphenicol may be used)

Dysentery (treated as shigellosis):

co-trimoxazole, ampicillin, nalidixid

acid


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ANTIPARASITIC FOR DIARRHEA

Amoebiasis metronidazole; if:

E. histolytica trophozoites containing RBC

(+) Bloody stools persist after tx for shigellosis

Giardiasis metronidazole; if:

Diarrhea more than 14 days Giardia containing stools


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MEDICATION NOT INDICATED FOR DIARRHEA

Sulphonamide

Neomycin & streptomycin

Clioquinol or oxyquinolone

Anti-peristaltic drug

Anti-vomiting drug

Kaolin

Steroid

Purgatif


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PREVENTION

Breast milk for the first 4-6 months of life

Avoiding the use of infant feeding bottles

Improving practices preparation & storage

of weaning foods Using clean water for drinking

Washing hands

Safely disposing of faeces

Measles vaccination Improving nutritional status weaning food

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Kuliah Tk IV Fkui Diarrhoea